Mandatory Counseling Questions

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BidingMyTime

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So, IL has is imposing a new mandatory counseling for all new patients, new RX's, and any changes to existing RX's. Of course, the state doesn't give any guidelines on what they expect this to look like, so I'm wondering what is expected/enforced in other states that already have these regulations.

How much detail is expected in the counseling, is it enough to say hey this is your new med, this is how you take it, this is the most common side effect to look for....or is something more in depth expected?

Also, how do you mark RX's requiring counseling? Just star the bag or something? I can see issues with this, when the verifying pharmacist doesn't mark the RX's requiring counseling, so the next shift when they are sold, it would be that RX that would get in trouble for not doing the mandatory counseling. And I can see where it will be easy to miss changes in existing RX's, most doctors just send over changes as a new RX and don't put anywhere on the RX that it is a change, so it seems like every new RX is going to have to be checked against the previous RX for that drug.

In states that already do this, does it feel like the cashier tech is constantly running back and forth to get the pharmacist to do the mandatory counseling? I'm guessing many pharmacies aren't going to be adequately staffed for this new level of counseling, but that's a separate issue.

I strongly suspect because of the shortage of cash in the state's funds, that they will see this as a great source of revenue to fine pharmacists for not properly doing the new counseling regulation. I think counseling is definitely a good thing, but the state making this huge change that goes into effect, and it was just announced it goes into effect in 3 days.....it seems like the state is setting this up so they can fine pharmacists and pharmacies, rather than setting it up giving pharmacies enough time and information to succeed at this.

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So, IL has is imposing a new mandatory counseling for all new patients, new RX's, and any changes to existing RX's. Of course, the state doesn't give any guidelines on what they expect this to look like, so I'm wondering what is expected/enforced in other states that already have these regulations.

How much detail is expected in the counseling, is it enough to say hey this is your new med, this is how you take it, this is the most common side effect to look for....or is something more in depth expected?

Also, how do you mark RX's requiring counseling? Just star the bag or something? I can see issues with this, when the verifying pharmacist doesn't mark the RX's requiring counseling, so the next shift when they are sold, it would be that RX that would get in trouble for not doing the mandatory counseling. And I can see where it will be easy to miss changes in existing RX's, most doctors just send over changes as a new RX and don't put anywhere on the RX that it is a change, so it seems like every new RX is going to have to be checked against the previous RX for that drug.

In states that already do this, does it feel like the cashier tech is constantly running back and forth to get the pharmacist to do the mandatory counseling? I'm guessing many pharmacies aren't going to be adequately staffed for this new level of counseling, but that's a separate issue.

I strongly suspect because of the shortage of cash in the state's funds, that they will see this as a great source of revenue to fine pharmacists for not properly doing the new counseling regulation. I think counseling is definitely a good thing, but the state making this huge change that goes into effect, and it was just announced it goes into effect in 3 days.....it seems like the state is setting this up so they can fine pharmacists and pharmacies, rather than setting it up giving pharmacies enough time and information to succeed at this.

I'm in California, which has mandatory counseling on new meds. It does sometimes feel like you are a human ping-pong ball, going back and forth between cashier and your workstation. It can get annoying, but you'll adjust.

To save time, I ask patient if they have had the medication before; a lot of times, the script might be new, but the patient has been on the med from an older (identical) script. If they have had it before, I ask them if they have any questions. ~90% of the time, they say no, and my work is done (note: per CA law, technicians/cashiers aren't allowed to ask if medication is new; only the pharmacist can ask that question. I'd check if this is the same for Illinois).

If they haven't had it before, then you can just jump right into counseling. Here, you can use your best judgement on what to say, but keep in mind that 1) most patients won't remember most of what you say, and 2) most patients won't get most side-effects most of the time, so narrow it down to maybe 3-4 bullet points.

As an example, for a new script of levofloxacin:
  • take with/without food, but drink plenty of water with it.
  • separate any antacids/multivitamins/minerals/dairy products by couple hours.
  • If they get tendinitis (especially in Achilles heal), stop taking and contact Dr ASAP.
  • If it's summertime/sunny, warn about photosensitivity/recommend sunblock as needed.
  • Generally, for all antibiotics, I ask about allergies, and tell patient to finish therapy, even if they are feeling better.
As far as marking a new script, depending on the chain you work for, there *should* be a notification on the label. If not, you can always put a big 'C' in red, and tell cashiers to watch out for it. The POS station should also have an option to mark that you did counsel the patient, though again, the specifics depend on the individual chain.
 
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My state is mandatory counseling on all new scripts. At CVS all of the pharmacists, at multiple stores, just flat out didn't do it and rather had the techs just ask if there were any questions. At Walmart it was very quick... indication, how to take it, 1-2 counseling points. Usually didn't take more than 30 seconds unless the pt had questions. In both cases the computer system would flag new scripts for counsel.

I've never heard of a state inspector going undercover to see if they were counseled... but it probably happens.
 
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My state is mandatory counseling on all new scripts. At CVS all of the pharmacists, at multiple stores, just flat out didn't do it and rather had the techs just ask if there were any questions. At Walmart it was very quick... indication, how to take it, 1-2 counseling points. Usually didn't take more than 30 seconds unless the pt had questions. In both cases the computer system would flag new scripts for counsel.

I've never heard of a state inspector going undercover to see if they were counseled... but it probably happens.
in Wisconsin all prescriptions, including refills, are mandatory consult. The rph usually asks if any questions on refills and consults on new rx's. It is a PITA but where it really gets tough is during flu season. Leave the pharmacy for 5 minutes to give a few immunizations and return to the pharmacy with 9 waiting customers that you have to ask if they have any questions on their refill before they are allowed to leave with their meds.
 
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I've never heard of a state inspector going undercover to see if they were counseled... but it probably happens.

Illinois is hard up for cash. Already they have a policy where inspectors can find violations, and if the offending pharmacy pays the fine immediately in cash, then the violation doesn't go on the record (this doesn't apply to serious violations.) The limiting aspect is that the state can't afford to hire inspectors to check out pharmacies, I think they only have like 7 or 8 inspectors for the entire state.
 
Illinois is hard up for cash. Already they have a policy where inspectors can find violations, and if the offending pharmacy pays the fine immediately in cash, then the violation doesn't go on the record (this doesn't apply to serious violations.) The limiting aspect is that the state can't afford to hire inspectors to check out pharmacies, I think they only have like 7 or 8 inspectors for the entire state.
rph's in WI are commonly fined by the state board for failing to consult (it shows up in the montly board publication)
 
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Illinois is hard up for cash. Already they have a policy where inspectors can find violations, and if the offending pharmacy pays the fine immediately in cash, then the violation doesn't go on the record (this doesn't apply to serious violations.) The limiting aspect is that the state can't afford to hire inspectors to check out pharmacies, I think they only have like 7 or 8 inspectors for the entire state.

That seems quite suspect. I would think a process like that would not be allowed just for risk of being sued for not equally enforcing the law. I mean, this would not fly for cops, "Oh hey I see you were speeding, give me $100 and no one will ever know" and I do not see how a random state investigator is any different than a cop for purposes of enforcing law.
 
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I'm in California, which has mandatory counseling on new meds. It does sometimes feel like you are a human ping-pong ball, going back and forth between cashier and your workstation. It can get annoying, but you'll adjust.

To save time, I ask patient if they have had the medication before; a lot of times, the script might be new, but the patient has been on the med from an older (identical) script. If they have had it before, I ask them if they have any questions. ~90% of the time, they say no, and my work is done (note: per CA law, technicians/cashiers aren't allowed to ask if medication is new; only the pharmacist can ask that question. I'd check if this is the same for Illinois).

If they haven't had it before, then you can just jump right into counseling. Here, you can use your best judgement on what to say, but keep in mind that 1) most patients won't remember most of what you say, and 2) most patients won't get most side-effects most of the time, so narrow it down to maybe 3-4 bullet points.

As an example, for a new script of levofloxacin:
  • take with/without food, but drink plenty of water with it.
  • separate any antacids/multivitamins/minerals/dairy products by couple hours.
  • If they get tendinitis (especially in Achilles heal), stop taking and contact Dr ASAP.
  • If it's summertime/sunny, warn about photosensitivity/recommend sunblock as needed.
  • Generally, for all antibiotics, I ask about allergies, and tell patient to finish therapy, even if they are feeling better.
As far as marking a new script, depending on the chain you work for, there *should* be a notification on the label. If not, you can always put a big 'C' in red, and tell cashiers to watch out for it. The POS station should also have an option to mark that you did counsel the patient, though again, the specifics depend on the individual chain.

Ping pong? Try tennis doubles. I'm in a state that requires counseling for all prescriptions, even refills. You can't do anything without being interrupted because they need you to go counsel on refills which nobody wants to hear.
 
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That seems quite suspect. I would think a process like that would not be allowed just for risk of being sued for not equally enforcing the law. I mean, this would not fly for cops, "Oh hey I see you were speeding, give me $100 and no one will ever know" and I do not see how a random state investigator is any different than a cop for purposes of enforcing law.

This is IL. I think we are like the most corrupt state in the union. 4 of our last 7 governors ended up in prison, and in more recent times 2 of our last 3 governors have gone to prison, now the 3rd and current one hasn't yet.....but that is a big yet. (and I think there was also a 5th one in the 7 that came close, but ended up getting acquitted or getting charges dropped.) Unfortunately, corruption has become accepted as a natural state of order in Illinois. And if you are wondering what the IL governors ended up going to jail for, the last one for trying to sell a senate seat that was vacant, the one before for selling commercial driver's licenses to unqualified people, the one before him for bank fraud, and the one before him for bribery. So yeah, this is IL.

Ping pong? Try tennis doubles. I'm in a state that requires counseling for all prescriptions, even refills. You can't do anything without being interrupted because they need you to go counsel on refills which nobody wants to hear.

That is ridiculous, they might as well just require the pharmacist to be the cashier. If states are going to take it upon themselves to pass laws regulating professional behavior, then they should be passing laws enabling those professionals to actually be able to follow the law.
 
That is ridiculous, they might as well just require the pharmacist to be the cashier.

ding ding ding ding ding!!!!! and that's how you maintain a productive pharmacy.

you have to find a balance. but i work in cali with mandatory counseling. and the best way to keep your sanity is to cashier and let your other coworkers work behind you. just bark orders at them and run over and bag up the waiting rx's. you can do some typing and data review between cashiering usually. of course you find a balance. you can get overwhelmed cashiering, and then you just need a tech/cashier to take over for a bit. but as soon as they take over you can guarantee you're gonna be interrupted for more consultations in a matter of seconds or minutes.
 
I wish all states were mandatory counseling. Do some of you really not counsel your patients when they pick up new medications? Sometimes I wonder about you guys.....I mean, you want us to be taken seriously for our knowledge yet you don't want to put it to use. Either way, I think this is a good thing. It will cut down on misfills and put more responsibility on the dispensing pharmacist.
 
My state is mandatory counseling on new scripts. I typically always ask if they had the medication before. Depending on answer, I just tell them the basic points of the medication like how to take it, what you can't consume while taking it and sometimes cautions. For dosage changes, for the most part the patient knows already but we just ask them anyway if they are aware the doctor changed the dosage.
 
WA state also has mandatory counseling on new scripts/changes. At Freddy's, the computer locks the release of the script unless a pharmacist or intern comes up to counsel and scan their badge to unlock. Usually interns do it because the pharmacists are busy. You just have to ask if they have questions, and 90% of the time its no and that's that. If you have interns or pharm students on rotations then its not a big deal because they can do it. With no interns though, its policy to finish out your current workflow before leaving to go counsel/scan to avoid mistakes. People just have to wait until a pharmacist is available.
 
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You just have to ask if they have questions, and 90% of the time its no and that's that.

That's a big no-no. Mandatory counseling is mandatory counseling. They can refuse but you can't offer that refusal.
 
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That's a big no-no. Mandatory counseling is mandatory counseling. They can refuse but you can't offer that refusal.

Yeah that was for changes to the script. I forgot to mention we ask "have you had this prescription before?" for new scripts. Then full counsel if they answer no, and quick counsel if they answer yes.
 
I trained in TN which is a mandatory counselling state. They would send under cover inspectors to ensure you were counselling. Don't counsel 3 patients in a row? That a $1,000 fine on the pharmacist for each occurrence.
 
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I've never heard of a state inspector going undercover to see if they were counseled... but it probably happens.
Doesn't happen in Hawaii. Our board hasn't budgeted for an inspector's salary in years.
 
I haven't seen inspectors that watch for counseling but there has apparently been a few inspectors that came in that made sure we followed the correct procedures for dispensing CIIs (ID verification etc).

That being said, new prescriptions here get mandatory counseling that we simply don't give patients the option of declining if the drug is new. But we don't have time for a long counseling session so the counseling is usually only like 30 seconds to a minute.
 
I go into an independent and commonly see 2-3 pharmacists on duty. At my chain, pharmacist overlap is rare except at the busiest stores. I wonder if there will come a time when the chains incur enough fines that they increase pharmacist hours? Until then, a lot of counseling is going to be left undone.
 
I go into an independent and commonly see 2-3 pharmacists on duty. At my chain, pharmacist overlap is rare except at the busiest stores. I wonder if there will come a time when the chains incur enough fines that they increase pharmacist hours? Until then, a lot of counseling is going to be left undone.

Some states the pharmacist themselves are fined. Not the pharmacy.
 
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I'm lucky...my state (MD) is only mandatory for new Medicaid scripts, and offer to counsel for all others. But since I'm newly minted, I still mark many prescriptions for consult required. Patients are grateful for the extra knowledge of their medication, but I'm not always sure the information will make a very big difference in how they take it or how they live their lives.
 
That's a big no-no. Mandatory counseling is mandatory counseling. They can refuse but you can't offer that refusal.

So let's say the following scenario unfolds: patient gets a script that is marked as new, and is sent to consultation window. The pharmacist who verified the script didn't notice anything out of the ordinary (potential DDI, duplicate therapy, allergy issues, etc.).

Pharmacist: Have you had this medication before?
Patient: Yes, for many years. The doctor just sent over a new prescription.
Pharmacist: I see. Any questions or concerns?
Patient: No.
Pharmacist: Ah. Well, if anything comes up, please let us know. Have a nice day!

Does this not follow the law for mandatory counseling?
 
This is IL. I think we are like the most corrupt state in the union. 4 of our last 7 governors ended up in prison, and in more recent times 2 of our last 3 governors have gone to prison, now the 3rd and current one hasn't yet.....but that is a big yet. (and I think there was also a 5th one in the 7 that came close, but ended up getting acquitted or getting charges dropped.) Unfortunately, corruption has become accepted as a natural state of order in Illinois. And if you are wondering what the IL governors ended up going to jail for, the last one for trying to sell a senate seat that was vacant, the one before for selling commercial driver's licenses to unqualified people, the one before him for bank fraud, and the one before him for bribery. So yeah, this is IL.



That is ridiculous, they might as well just require the pharmacist to be the cashier. If states are going to take it upon themselves to pass laws regulating professional behavior, then they should be passing laws enabling those professionals to actually be able to follow the law.

Right??? Techs do try hard to get me to ring people up. I don't. As it is, I already spend my days doing their job in addition to mine.
 
So let's say the following scenario unfolds: patient gets a script that is marked as new, and is sent to consultation window. The pharmacist who verified the script didn't notice anything out of the ordinary (potential DDI, duplicate therapy, allergy issues, etc.).

Pharmacist: Have you had this medication before?
Patient: Yes, for many years. The doctor just sent over a new prescription.
Pharmacist: I see. Any questions or concerns?
Patient: No.
Pharmacist: Ah. Well, if anything comes up, please let us know. Have a nice day!

Does this not follow the law for mandatory counseling?

No. In your scenario the pharmacist offered counseling and the patient declined. You cannot offer counseling in a mandatory counseling state. You have to counsel and only then can they refuse. What if that medication was Keflex? Passes DUR, interaction check is great, no duplicate therapy or allergy, etc. In reality the voicemail that resulted in the prescription was for Keppra, not Keflex. Using your scenario, your failure to counsel could have caused harm to the patient. This is why counseling is now mandatory. You cannot offer it. You must give it.
 
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"Have you had this medication before" is indeed considered an "offer" and would get you easily fined in California if an inspector is observing. There are known situations where an inspector sits in the waiting area and then identifies him/herself as an inspector upon being addressed by pharmacy staff.
 
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No. In your scenario the pharmacist offered counseling and the patient declined. You cannot offer counseling in a mandatory counseling state. You have to counsel and only then can they refuse. What if that medication was Keflex? Passes DUR, interaction check is great, no duplicate therapy or allergy, etc. In reality the voicemail that resulted in the prescription was for Keppra, not Keflex. Using your scenario, your failure to counsel could have caused harm to the patient. This is why counseling is now mandatory. You cannot offer it. You must give it.

Well, in my scenario, I would first tell the patient what the medication is, so they know which one they are picking up. We have had at least one incident where we accidentally filled for the wrong med (sound-alike), but because no one told her what it was, she just picked it up.

But if you have to jump right into counseling, how can the patient refuse? Aside from cutting the pharmacist off, I can't think of how this could happen...
 
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Cutting the pharmacist off is exactly what happens, like when the patient gets pissed off and says things "I don't have time for this" or "I've been a nurse for 40 years" before stating they don't want consultation.
 
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Cutting the pharmacist off is exactly what happens, like when the patient gets pissed off and says things "I don't have time for this" or "I've been a nurse for 40 years" before stating they don't want consultation.

Gonna be honest, I've never had someone cut me off while counseling... they might have said to the tech beforehand that the med wasn't new, but one at counseling window, they stay polite.

Then again, if patient says they have taken med before, and don't have questions, I send them on their merry way. If I forced counseling on every med that CVS dictated was new but really wasn't, then I wouldn't blame the patients for getting annoyed. Mandatory counseling makes sense for a legitimately new script, or for specific issues/questions, but beyond that, it gets silly.
 
It's more like "why do I have to go through this blah blah blah blah" right after you acknowledge them

And then if the people don't speak any English then you have to call for the translation service because they can't exactly communicate refusal (in English not in body language) without a translator
 
So let's say the following scenario unfolds: patient gets a script that is marked as new, and is sent to consultation window. The pharmacist who verified the script didn't notice anything out of the ordinary (potential DDI, duplicate therapy, allergy issues, etc.).

Pharmacist: Have you had this medication before?
Patient: Yes, for many years. The doctor just sent over a new prescription.
Pharmacist: I see. Any questions or concerns?
Patient: No.
Pharmacist: Ah. Well, if anything comes up, please let us know. Have a nice day!

Does this not follow the law for mandatory counseling?
I use a different strategy for counseling for patients new to a drug and those who have been taking it. For patients who have been taking meds, I ask them to tell me how they're taking the medication and/or if they've had specific expected adverse effects. There is plenty to counsel on for everyone, just don't waste their time with the same script you'd use on a naive patient.
 
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Cutting the pharmacist off is exactly what happens, like when the patient gets pissed off and says things "I don't have time for this" or "I've been a nurse for 40 years" before stating they don't want consultation.

THANK YOU!!! That's exactly what happens,OP. You just have to start talking until they cut you off. If you're at a store that does 2000+ scripts/week, you'll have to drop whatever you're doing to run over to the window and be interrupted again. *cycle repeats x 250 pickups.
 
I wish all states were mandatory counseling. Do some of you really not counsel your patients when they pick up new medications? Sometimes I wonder about you guys.....I mean, you want us to be taken seriously for our knowledge yet you don't want to put it to use. Either way, I think this is a good thing. It will cut down on misfills and put more responsibility on the dispensing pharmacist.

No, mandatory counseling creates unnecessary interruptions to your workflow. When you're verifying input or products, You can't go 15 seconds straight without an interruption. Then you rush over there only to hear "I've had these for years"

The majority of mistakes -wrong product, wrong directions- are caught at Input verification. For Walgreens, that's "F4", for those who use the McKesson system that's "pre-verification", Walmart 4Point, etc. If an error is not caught at this point, it is unlikely to get caught because it will get filled and if it's filled correctly, it will scan just fine even if it the wrong drug was entered. Then at Visual Verification, most pharmacist are just looking at the pill and don't look at the script. To be fair, most companies do not require that you look at the script again at Visual Verification as part of their best practices. All those constant interruptions lead to extreme mental fatigue and eventually, you'll make a mistake.
I have seen both sides. Thus, I feel I can speak from first-hand experience. I am licensed in two states; one with mandatory counseling on everything and the second state, has mandatory counseling only on new prescriptions. The pharmacist may also exercise professional judgment and waive the counseling requirement if this "new" prescription is a renewal and there aren't any changes in therapy and if in the professional judgment of the pharmacist the patient has shown adherence and they're fine and will be fine.
In this second state, the pharmacist may have 6 mandatory consults in one day if it's a REALLY busy store. Mistakes rarely ever happen because you aren't interrupted to go Counsel on nothing really because all you're doing is an additional Visual verification, right there in front of the patient, which to me, it may give patients the impression that at moment is when the pharmacist visually verifies the drugs. Some companies require "show and tell" on everything, even refills. The whole frantic display does not look reassuring, by any means.
So in this second state, refills are carefully matched with their paperwork and bags are stapled shut and the state allows the pharmacist to opt those scripts out of mandatory counseling.
The last person to touch that bag is a pharmacist who then staples it shut. Then patient picks up their refills. Offer is made. Then they confirm that "it's just refills". The pharmacist is never dragged into any of this at any point of this perfunctory process.
Now let me tell you how different from that it is in the first state I mentioned. Like I said, the pharmacist has to rush up there and check the vials and basically do a 3rd Visual. The countless times I have run into cr@p in those bags who were last touched by a careless tech or worse a CLERK... And then I have to quickly scramble. I catch a lot of errors because if I'm going to jeopardize my license by dropping everything that I am doing to run over there, I am going to make sure everything in that bag is right. I'm basically that guy that turns on the blinker when switching lanes or making a turn whether I'm the only soul out on the street or not.
Oh and this state with mandatory counseling does not require technicians to be certified. So really? Let's work pharmacists to death and they can do so with unskilled laborers? Sounds great. So you can imagine, that your license is on the line at all times. So you have techs that are NOT CERTIFIED entering prescriptions and they make mistakes left and right. Call them turtles... and they will send trash at you on purpose. They don't care. And then they will summon the "open door policy" and a lot of you know how that goes - when you get "open door-ed".
In the second state, all techs are required to be certified - end of story. If you can't handle that, go back to "grocery" or cashier.
In the second state, whenever I stapled shut that bag, I was ready to let it go for good. But in the first state -where I work now- , I never know what kind of cr@p I am going to find in the bag.

So the board of pharmacy of that first state has failed to see that ultimately, dragging the pharmacist up there is going to lead to more mistakes. And they will only get caught if you're really paying attention. I'd say 55% of the pharmacists I've run into in state #1 are paying attention. The other 45% aren't.

How many job openings each state has tells you a lot about not only the working conditions but also the efficiency of the quality assurance system in place and whether pharmacists are embracing it or not. In other words, do pharmacists want to work there or not? The drive to the other state is literally 20 minutes. It's no big deal. If you really wanted to, you could move closer but why would you go over there to work TWICE as HARD and HALF as SMART. In the second state, you do "double checks". Most companies do overload their pharmacists with piles of California bundles to be checked and initialed within 72 hours of RPH verification. HOWEVER, other companies; i.e., one of them is Walmart, have embraced a paperless system by adding a "double check" queue that done after the final visual verification. It's basically a check on the initial Input verification done by the first pharmacist. You catch a lot of mistakes that way, especially if you are not the only RPH on duty. If you are by yourself, you have to wait 2 hours to do the double check. HOWEVER, if there is an intern or another pharmacist, the double check can be done almost immediately *I think. Often times, when these errors are caught, the bag is still in the Will Call Bin. Thus, no harm done. As opposed to that frantic display at the counseling window.

In state #1, it's very hard to fill retail positions. plenty of jobs to choose from. If you take a job in this state, you're always checking for an opening anywhere across the river.

In state #2, nothing ever opens. Pharmacists know they have it good. They don't get home DRAINED to their families. They are able to do it all over again the next day and get through the day.

One more thing, yes, I share my knowledge to the patient but if it is a true new medication I also gently remind them it's up to them. "Oh, the pharmacist didn't tell me that my epidermis would detach from my dermis if I didn't follow the schedule for this med". None of that nonsense. I open the patient leaflet and tell them "your prescriber wants you to take one twice daily etc. the most common side effect is ......./ food or no food. Make sure you go through this leaflet. This is YOUR GUIDE."
I'm always happy to share and sure, I can show them how to use their Breo Ellipta but given that I have to go up to the consultation window for no reason at all 200 times a day, I keep it succinct and direct them to the manufacturer website which likely has videos or YouTube. I even pull out my phone and walk them how to do it on theirs.

I hope this sheds some light onto why some of us who work in a state with mandatory counseling appear so bent out of shape and burnt out. Of course we all make choices and I'll get out as soon as that is an option.
 
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